1. REPRODUCTIVE ANATOMY & PHYSIOLOGY

2. EARLY DEVELOPMENT Male & Female organs
produce sex cells
transport for union
Sex Differentiation at 8 weeks of life
Ovary - produces oogonia at 10 weeks of fetal life; approximately 150,000 oocytes present at birth
Testes - produces spermatoza at 7-8 weeks

3. Reproductive Anatomy External Organs Mons Pubis Labia Majora
Labia Minora
Clitoris
Vaginal Vestibule
Urethral meatus
Skene’s Glands
Hymen
Fourchete
Perineum

4. Figure 2–1 Female external genitals, longitudinal view.

5. Reproductive Anatomy con.
Internal Organs
Vagina
Uterus
Fundus
Corpus
Isthmus
Cervix

6. Figure 2–2 Female internal reproductive organs.

7. Layers of the Uterus Perimetrium Myometrium Endometrium
outer layer composed of peritoneum
Myometrium
inner layer primarily in the fundus; longitudinal fibers; causes cervical effacement and power to express the baby
Endometrium
innermost layer, produces endometrial milk, undergoes monthly regeneration

8. Figure 2–4 Structures of the uterus.

9. Myometrium Muscular Layer - composed of 3 distinct layers
Longitudinal fibers found mainly over the fundus; most involved with birth of fetus
Fibers interlaced with blood vessels in Figure 8 pattern; living ligature – helps stop bleeding
Circular fibers concentrated around fallopian tubes and cervical os; helps keep cervix closed

10. Figure 2–5a Uterine muscle layers. Muscle fiber placement.

11. Internal Organs con. Isthmus Cervix Joins corpus to the cervix
Site for lower C/S
Cervix
Composed of fibrous connective tissue
Length 2.5 to 3 cm (~1-2”)
Functions
Passage of menses and sperm
Produces mucus in response to cyclic hormones
Frequent site for uterine cancer

12. Bottom of Cervix, Cells are taken from here for Pap Smear

13. Uterine Ligaments Think which ligaments cause pain during pregnancy
Broad ligament – stabilizes uterus, covers uterus anteriorly and posteriorly
Round ligament – helps keep uterus in place from the sides, pain on sides late in pregnancy
Ovarian ligament – anchors lower part of ovary, helps catch ovum in fimbriae
Cardinal ligament – chief uterine support, prevents uterine collapse
Uterosacral ligament – support for uterus at level of the ischial spine, source of menstrual pain

14. Figure 2–5b Interlacing of uterine muscle layers.

15. Figure 2–6 Uterine ligaments.

16. Fallopian Tubes
Functions – provide passageway for ovum into uterus, site for fertilization
Fimbriae – most distal part, wavelike motion that pulls ovum into tube
Ampulla – site for fertilization
Isthmus - close to uterus, site for BTL

17. Figure 2–7 Fallopian tubes and ovaries.

18. Ovaries At birth, all ova are contained within immature follicles
Functions
Ovulation
Produce hormones

19. Bony Pelvis
Functions – to support and protect the internal organs of reproduction
Innominate Bones
Ilium – upper prominence of hip
Ischium – under the ilium, ends in ischial tuberosity, serves as reference point for station
Pubis – (2 separate bones) front of innominate, meets other to form symphysis pubis
Sacrum – 5 fused vertebrae, sacral promontory
Coccyx – (Tail bone) triangular bone last on vertebral column, moves backward in childbirth (Sometimes can get fx’d during childbirth)

20. Figure 2–8 Pelvic bones with supporting ligaments.

21. Pelvic Floor (Muscles)
Designed to overcome force of gravity
Provides stability and support for surrounding structures (Help body remain intact, until baby is ready for birth)
Pelvic diaphragm – deep fascia, levator ani, and coccygeal muscles
Muscles function as a whole, yet are able to move over one another – provides capacity for dilatation

22. Figure 2–9 Muscles of the pelvic floor
Figure 2–9 Muscles of the pelvic floor. (The puborectalis, pubovaginalis, and coccygeal muscles cannot be seen from this view.)

23. Pelvic Division
False Pelvis – portion above pelvic brim or inlet; serves to support pregnant uterus; helps direct presenting part into true pelvis
True Pelvis – portion below linea terminalis; represents the bony limits of the birth canal
Pelvic inlet – upper border of true pelvis
Pelvic outlet – lower border of true pelvis

24. Figure 2–10a Female pelvis
Figure 2–10a Female pelvis. False pelvis is shallow cavity above the inlet; true pelvis is deeper portion of cavity below the inlet.

25. Figure 2–10b True pelvis consists of inlet, cavity (midpelvis), and outlet.

26. Figure 8–5a Manual measurement of inlet and outlet
Figure 8–5a Manual measurement of inlet and outlet. Estimation of the diagonal conjugate, which extends from the lower border of the symphysis pubis to the sacral promontory.

27. Figure 8–5b Estimation of the anteroposterior diameter of the outlet, which extends from the lower border of the symphysis pubis to the tip of the sacrum.

28. Pelvic Measurements Helps figure whether baby’s head can fit.
Diagonal conjugate – extends from the subpubic angle to the middle of the sacral promontory; can be measured manually (with hand) during a pelvic exam
Take and substract 1.5cm to get Obstetric conjugate.
Obstetric conjugate – extends from the middle of the sacral promontory to 1 cm below the pubic crest (Cannot be reached/measured manually)
Conjugate vera – extends from the middle of the sacral promontory to the pubic crest

29. Figure 2–11 Pelvic planes: coronal section and diameters of the bony pelvis.

30. C D
Figure 8–5 c & d Methods that may be used to check the manual estimation of anteroposterior measurements.

31. Figure 8–6 Use of a closed fist to measure the outlet
Figure 8–6 Use of a closed fist to measure the outlet. Most examiners know the distance between their first and last proximal knuckles. If they do not, they can use a measuring device.

32. Pelvic Types Gynecoid – most common female, adequate
Android – most common male, not adequate
Anthropoid – usually adequate
Platypelloid – usually not adequate

33. Figure 15–1 Comparison of Caldwell-Moloy pelvic types.

34. Female Sex Hormones Estrogen
Maturation of secondary sex characteristics
Secreted by the maturation of ovarian follicles
Cause proliferation of endometrial mucosa
Causes increase in size and weight; closure of long bones
Increases myometrial and fallopian tube contractility
Increases uterine sensitivity to oxytocin
Maintains bone density
Inhibits FSH production and stimulates LH production
May increase libido

35. Female Sex Hormones con.
Progesterone “keeps everything quiet”; maintains pregnancy
LH stimulates corpus luteum to secrete progesterone
Decreases motility and contractility of uterus
Proliferates vaginal epithelium
Causes cervix to secrete thick viscous mucus
Anti-sperm
Prepares breast tissue for lactation
Thermogenic “heat producing”
check temp to determine ovulation
“Hormone of Pregnancy”

36. Female Sex Hormones con.
Prostaglandins
Produces by the endometrium “lining of the uterus”
Differentiated by Roman letters and numbers or Greek numbers
Essential for ovulation (help egg be expelled from the ovary)
Causes expulsion of the ovum
Produces progesterone withdrawal
Facilitates tissue digestion to cause endometrial shedding

37. Neurohormonal Basis of the Female Reproductive Cycle Causes menses cycle to occur
Controlled by an interaction between the nervous and endocrine systems and their target tissues – hypothalamus, anterior pituitary, and ovaries

38. NEUROHORMONAL BASIS OF THE FRC
CNS --- HYPOTHALMUS RELEASES ----GnRF (FSHRH & LHRH) CAUSES ANTERIOR PITUITARY TO RELEASE FSH & LH ---- STIMULATES GONADS TO SECRETE HORMONES (ESTROGEN & PROGESTERONE)
In males, LH induces secretion of testosterone.
In females, LH working w/ FSH stimulate follicle growth in ovary to secrete estrogen.

39. Ovarian Cycle Be able to know which cycle the woman is in
1st Part- Follicular Phase (Follicles- where the immature eggs are contained)
Starts with day 1 menses; 1-14 days; may vary
multiple follicles are maturing; one is selected; when mature, called a graafian follicle; surrounded by fluid …and becomes a cyst on the ovary.
Comes close to surface of ovary, forms a blister, ovum pushed out of the follicle near the fimbria (ovulation)
Pain at mid-cycle Mittelschmerz (may see blood spotting)
Pulled into fallopian tube and travels to ampulla where fertilization can occur

40. Ovarian Cycle con. 2nd Part- Luteal Phase
Begins with ovulation (the second half of ovarian cycle)
Corpus luteum develops from the ruptured follicle
If fertilized, the ovum implants into endometrium
Ovum secretes HCG to maintain corpus luteum; the corpus luteum secretes progesterone and estrogen (cause you have to have high levels of H to maintain preg)
If no fertilization, degenerates in about a week and becomes the corpus albicans
Estrogen and Progesterone decrease which stimulates FSH and LH to be released which will start whole cycle over again.
14 days after ovulation, menses begins (this remains constant) A person can then predict ovulation.

41. Figure 2–14 Various stages of development of the ovarian follicles.

42. Endometrial Cycle- 4 Phases
1) Menstruation
Cyclic uterine bleeding in response to hormones changes; begins 14 days after ovulation
Partial shedding of the endometrium
Discharge made up of blood, fluid, cervical and vaginal secretions, bacteria, leukocytes and cellular debris; dark red, distinctive odor
Menarche- onset of menstruation; age 9-16
Cycle lengths vary days; illness, fatigue, stress, anxiety, vigorous exercise can alter cycle

43. Endometrial Cycle con. 2) Proliferative 3) Secretory 4) Ischemic
Endometrium increases 6-8 fold, estrogen incr/peaks, cervical mucus becomes thin (to allow sperm to pass), BBT drops at ovulation then increases (Progesterone levels incr)
3) Secretory
Estrogen decreases, progesterone dominates, vascularity of uterus increases, glands begin to secrete endometrial milk for fertilized ovum
4) Ischemic
If no fertilization, corpus luteum begins to degenerate; estrogen and progesterone levels fall; leads to tissue necrosis and small blood vessels rupture, arteries constrict decreasing blood supply to endometrium;  tissue pale, menses begins

44. Figure 2–13 Female reproductive cycle: interrelationships of hormones with the four phases of the uterine cycle and the two phases of the ovarian cycle in an ideal 28-day cycle.

45. Physical and Psychological Changes of Pregnancy

46. Three Pregnancy Periods
Antepartum- from conception to the onset of labor
Intrapartum- from the onset of labor to the first 1-4 hours after delivery of newborn and placenta
Postpartum- refers to the 6 weeks after delivery of the newborn and placenta.

47. Pregnancy
Nine months of pregnancy are divided into three trimesters, each are three months long.
All systems of a woman’s body are altered in some way during pregnancy.

48. Changes of the Reproductive System
Uterus - increases in capacity and size; requires one-sixth of maternal blood flow.
Braxton Hicks - irregular contractions, usually painless, felt throughout pregnancy, can be confused with true labor later in pregnancy
Ovaries – stop ovulation; corpus luteum continues to produce hormones until 6-8 weeks
Uterus - increases in capacity from 10mls to 5L; this increase is primarily caused by an increase in size of cells in response to estrogen, as well as distension of the growing fetus; by the end of the pregnancy, the uterus and its contents require up to one-sixth of the total maternal blood flow. The uterine stretching causes braxton hicks contractions.
Braxton Hicks contractions > irregular contractions, usually painless, felt throughout pregnancy, can be confused with true labor later in pregnancy

49. Change in the Reproductive System
Cervix - secretes mucus that forms a plug
Goodell’s sign - softening of the cervix
Chadwick’s sign - bluish color of the cervix during pregnancy
Vagina - mucosa thickens and connective tissue relaxes; pH acidic favors yeast
under the influence of estrogen, the cervix secretes mucus that forms a plug at the opening of the endocervical canal to limit bacteria entering the uterus; increased blood flow to the cervix results in two signs:
under the influence of estrogen, vaginal mucosa thickens and connective tissue relaxes; vaginal secretions thicken and increase in amount during pregnancy; the pH is acidic, 3.6 – Acidic pH favors growth of yeast organisms.

50. Changes in the Reproductive System cont
Breasts - increase in size and number of glands
Colostrum - thin yellow secretion high in protein and immune properties
Breasts > estrogen and progesterone cause the breasts to increase in size and to increase in the number of glands; colostrum is produced and may be expressed during the last trimester.
Colostrum > a thin yellow secretion high in protein and immune properties

51. Changes in the Cardiovascular System
Cardiac output - increases 30-40%
Pulse – increases bpm
BP - decreases in the 1st and 2nd trimesters; 3rd trimester increases to pre-pregnant levels
Vena cava syndrome – (Caution!) uterus compresses the vena cava
S/S: pallor, dizziness and clammy skin
Cardiac output increases 30 to 40% over nonpregnant output with an increase in pulse of beats/minute.
Pulmonary and peripheral vascular resistance decreases 40 to 50%, lowering the BP throughout the first and second trimesters; in the third trimester, it begins to increase to pre-pregnant levels; postural hypotension may result as the pregnant uterus presses on pelvic and femoral vessels limiting blood return to the heart
Supine hypotension syndrome or vena cava syndrome results as the gravid uterus compresses the vena cava resulting in decreased blood flow to the right atrium and a decrease in blood pressure.
> S/S include pallor, dizziness and clammy
skin
> Problem can be prevented or treated by
positioning the woman on her left side with a
pillow under her right hip.

52. Figure 7–1 Vena caval syndrome
Figure 7–1 Vena caval syndrome. The gravid uterus compresses the vena cava when the woman is supine. This reduces the blood flow returning to the heart and may cause maternal hypotension.
Caution for Vena cava syndrome!!! Keep head elevated or turn to one side.

53. Cardiovascular System cont
Blood (More volume, but blood is diluted)
volume increases 45%
RBCs increase 18 to 30%
Plasma volume increases 50%
Physiologic anemia – more diluted
Blood volume increases 45% over pre-pregnant levels. RBCs increase 18 to 30% depending on the degree of iron supplementation.
Plasma volume increases 50%
The greater increase in plasma over RBCs results in physiologic anemia with a decrease on hemoglobin (10-14 grams/dL) and hematocrit (32-42%) the drop in hematocrit is approximately 5 to 7%.

54. Changes in the Respiratory System
Growing uterus elevates the diaphragm
Increased 02 needs
Increased air volume exchange
Nasal stuffiness and epistaxis from increased estrogen

55. Changes of the Musculoskeletal System
Teeth/gums – bleeding gums; oral hygiene important to prevent preterm labor
Relaxation of the pelvic joints – “Waddling” gait
Physiologic lordosis - lumbar spinal curvature increases compensating for weight of uterus
Diastasis recti - separation of the rectus abdominal muscle

56. Figure 7–3 Postural changes during pregnancy
Figure 7–3 Postural changes during pregnancy. Note the increasing lordosis of the lumbosacral spine and the increasing curvature of the thoracic area.

57. Changes of the Gastrointestinal System
1st trimester – Incr HCG causes N/V
Increased progesterone levels – causes decreased peristalsis  reflux and constipation (Fiber and fluids important)
Hemorrhoids - constipation and increased pressure on blood vessels in the rectum

58. Changes of the Renal System
Urinary frequency
Glomerular filtration - increases 50%
Glycosuria – more prone to develop gestational diabetes.
Changes of the Renal System
In the first trimester, the gravid uterus presses on the bladder causing urinary frequency; this is relieved in the second trimester because the uterus moves into the abdominal area, this returns in the third trimester as the presenting part presses on the bladder.
Glomerular filtration increases 50% during the second trimester and remains elevated until delivery; the kidneys may not be able to reabsorb all of the glucose filtered resulting in glycosuria.
Glycosuria, if present may indicate development of gestational diabetes.

59. Changes in the Integumentary System
Increased pigmentation - areola, nipples and vulva
Chloasma - mask of pregnancy
Linea nigra - darkly pigmented line from umbilicus to the pubic area
Striae gravidarum - stretch marks
Sweat and sebaceous gland activity increases
Changes in the Integumentary System
In response to increased levels of estrogen, some areas of the skin have an increase of pigmentation
This is seen primarily in areas with increased pigmentation such as the areola, nipples and vulva
Chloasma > mask of pregnancy, is an increase in pigmentation on the forehead and around the eyes; it is seen most often in women of color and is aggravated by sun exposure.
Linea nigra > is a darkly pigmented line that extends from the umbilicus to the pubic area.
Striae gravidarum > or stretch marks, appear as reddish streaks on trunk and thighs; they result from the stretching of connective tissue caused by increased adrenal steroids; while these generally change to a shiny gray-white color after delivery, they do not disappear.
Sweat and sebaceous gland activity increases during pregnancy.

60. Changes in the Endocrine System
Metabolism - increases
Weight gain – Norm 3 to 5 pounds 1st trimester; 1 pound/week 2nd and 3rd trimesters. (Avg 25-35lb incr throughout preg)
Water retention - increased sex hormones and decreased serum protein
Water retention occurs during pregnancy caused by increased sex hormones and decreased serum protein

61. Endocrine System cont Hormones
Human chorionic gonadotropin (hCG)- Present only during preg, causes the N/V
Human placental lactogen (hPL)- Maintainance of preg; is an insulin antagonist; it promotes lipolysis.
Estrogen- incr growth of uterus and stimulates the breast for lactation.
Progesterone “keeps uterus quiet” maintains the endometrium, decreased uterine contractility, and causes relaxation of smooth muscle.
Relaxin- decreases uterine contractility, contributes to the softening of the cervix
Postaglandins- some contract, some relax
Human chorionic gonadotropin (hCG), stimulates progesterone and estrogen production; it is thought to support the pregnancy and cause nausea and vomiting in the first trimester.
Human placental lactogen, hPL, is a insulin antagonist; it promotes lipolysis, resulting in increased amounts of circulating free fatty acids available for metabolic use.
Estrogen stimulates uterine development to support fetal growth and stimulates the ductal system of the breast for lactation.
Progesterone maintains the endometrium, decreased uterine contractility, stimulates development of breast, and causes relaxation of smooth muscle.
Relaxin decreases uterine contractility, contributes to the softening of the cervix, and has long-term effects on collagen.
Postaglandins are lipids that are found throughout the reproductive system, contribute to the decrease seen in the placental vascular system, and probably

62. Signs and Symptoms of Pregnancy
3 categories: presumptive, probable and positive.
1) Presumptive – woman reports
Amenorrhea
Nausea and vomiting
Fatigue
Urinary frequency
Breast changes- tender/darker
Quickening- From feeling the baby move
Define: Quickening- the process of showing signs of life.
Define: Presumptive- signs of pregnancy, ex: morning sickness

63. Signs and Symptoms of Pregnancy
2) Probable - Noted by examiner
Goodell’s sign - softening of cervix
Chadwick’s sign - bluish color, cervix, vagina
Hegar’s sign - softening of lower uterine segment
Enlarged abdomen
Pigmentation changes
Stretch marks
Ballottement- A method of diagnosing pregnancy, in which the uterus is pushed with a finger to feel whether a fetus moves away and returns again.
Positive pregnancy test
Palpation of fetal outline

64. Figure 7–4 Hegar’s sign, a softening of the isthmus of the uterus, can be determined by the examiner during a vaginal examination.

65. Signs and Symptoms of Pregnancy
3) Positive
Noted by examiner - only caused by pregnancy
Fetal heartbeat
Fetal movement palpable by the examiner
Visualization of the fetus by ultrasound

66. Psychological Response of the Expectant Family to Pregnancy
Turning point in a family’s life
Role changes
Financial changes
Fear and anxiety
Developmental tasks for mom and dad
Cultural values and beliefs

67. Maternal Reactions and Responses to Pregnancy
1st Trimester
Feelings of disbelief and ambivalence
Baby does not seem real
Focuses on herself and pregnancy
May experience early s/s of pregnancy
Introspective
Mood swings
Fantasize about miscarriage (Many women fear miscarriage, usually w/in the 1st trimester)

68. Maternal Reactions and Responses to Pregnancy
2nd Trimester
Quickening - baby a real separate person.
Mom excited about pregnancy
Helps plan her future and child’s future
Experiences body image changes
Concern about partner’s support

69. Maternal Reactions and Responses to Pregnancy
3rd Trimester
Pride in pregnancy
Anxious about labor
Concern about baby’s health
Surge of energy close to delivery date

70. Rubin’s Maternal Tasks What mom wants
Ensuring safe passage for fetus
Seeking acceptance of fetus by others
Assumption of mother role
Learning to give of oneself on behalf of one’s child

71. Paternal Psychological Responses to Pregnancy of Partner
Pride in pregnancy– virility; Manly character; The ability to procreate
Ambivalence- a state in which one experiences conflicting feelings (Ambi- “both”) Ex: concerns about readiness
Stress
Concerns and fears
Couvades- may experience certain rituals during the fatherhood transition. Also may experience certain pregnancy s/s felt by partner such as nausea, cravings and weight gain.
Pride in pregnancy
Ambivalence - concerns about readiness for responsibilities of parenthood
Stress - may feel pressure for added financial support
Concerns and fears > change in relationship, health of baby and partner
Couvades > may experience certain rituals during the fatherhood transition. Also may experience certain pregnancy s/s felt by partner such as nausea, cravings and weight gain.

72. Other Family Members Reaction
Sibling rivalry
Threat
Regression
Preparation
Include
Grandparents
Increase support
Childrearing practices